Hemorrhoid disease is an extremely common condition that causes persistent and severe symptoms, such as prolapse, bleeding, and discomfort. More rarely, hemorrhoids can become thrombosed, or ischemic and gangrenous, requiring emergency therapy. An estimated 4 million people per year have symptoms relating to hemorrhoids, while approximately one million seek treatment.
Traditional hemorrhoid management includes conservative therapies for minimally troubling hemorrhoid disease, with step-wise progression of invasive therapies for more symptomatic (usually larger) hemorrhoids. The next level of hemorrhoid therapy often utilizes rubber band ligation (generally, an office-based procedure), infra-red coagulation (not really proven or widely accepted), or sclerotherapy. Patients with persistent symptoms who fail these treatments require progression to operative surgery.
Operative hemorrhoid surgery is usually performed under general anesthesia as a day-case procedure. The traditional hemorrhoid surgery has been an excisional hemorrhoidectomy, most commonly a Ferguson or Milligan-Morgan procedure. These procedures are typically uncomfortable and usually require a procedure in the operating room.
More recently, the Procedure for Prolapsing Hemorrhoids (PPH) has been used to treat hemorrhoid disease. This procedure uses a circular stapler to excise a circular ring of tissue several centimeters inside the anal canal to retract the anoderm and reduce the hemorrhoids. In several studies, PPH has been shown to provide an equivalent outcome to excisional surgery, with pain scores that are significantly improved in the post-operative period (generally about 3-4 points lower than excisional hemorrhoidectomy on a 10 point VAS score). The disadvantages of PPH, however, are that i) the results are essentially no better than traditional hemorrhoidectomy (except for pain scores); ii) general anesthesia is required; iii) day-case hospital admission is required; iv) the circular stapler is a relatively expensive device (compared to cautery and absorbable suture for excisional hemorrhoidectomy); and v) PPH is a relatively new procedure that requires a new CPT code and requires surgeons to be specifically trained for this procedure. Furthermore, several serious complications of the PPH procedure have been described.